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Systematic Realist Review of Key Factors Affecting the Successful Implementation and Sustainability of the Liverpool Care Pathway for the Dying Patient

Authors

  • Tracey McConnell BSc (Hons), MSc,

    1. Doctoral student, School of Nursing and Midwifery, Queen's University of Belfast, Belfast, Northern Ireland
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  • Peter O'Halloran RN, PhD,

    Corresponding author
    1. Lecturer, School of Nursing and Midwifery, Queen's University of Belfast, Belfast, Northern Ireland
    • Address correspondence to Dr. Peter O'Halloran, School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland; p.ohalloran@qub.ac.uk

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  • Sam Porter RN, PhD,

    1. Professor, School of Nursing and Midwifery, Queen's University of Belfast, Belfast, Northern Ireland
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  • Michael Donnelly PhD

    1. Reader, Centre of Excellence for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Belfast, Northern Ireland
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  • Author contributions: Tracey McConnell was primarily responsible for the development of the review including the design, analysis and interpretation, and initial draft of the manuscript. Co-authors, Drs. Peter O'Halloran, Michael Donnelly and Professor Sam Porter contributed to conceptualisation of the paper, critique of the analysis and synopsis of findings. All provided editorial contributions and approved the final version of the manuscript.

  • Tracey McConnell was supported during this work by a research studentship from the Centre for Health Improvement, Queen's University Belfast.

ABSTRACT

Background

The Liverpool Care Pathway (LCP) is recommended internationally as a best practice model for the care of patients and their families at the end of life. However, a recent national audit in the United Kingdom highlighted shortcomings; and understanding is lacking regarding the processes and contextual factors that affect implementation.

Aim

To identify and investigate factors that help or hinder successful implementation and sustainability of the LCP.

Methods

Electronic databases (Medline, CINAHL, British Nursing Index, Science Direct) and grey literature were searched, supplemented by citation tracking, in order to identify English language papers containing information relevant to the implementation of the LCP. Using a realist review approach, we systematically reviewed all relevant studies that focused on end of life care and integrated care pathway processes and identified theories that explained how the LCP and related programmes worked.

Results

Fifty-eight papers were included in the review. Key factors identified were: a dedicated facilitator, education and training, audit and feedback, organisational culture, and adequate resources.

Discussion

We discuss how these factors change behaviour by influencing the beliefs, attitudes, motivation and confidence of staff in relation to end of life care, and how contextual factors moderate behaviour change.

Conclusions

The implementation process recommended by the developers of the LCP is necessary but not sufficient to ensure successful implementation and sustainability of the pathway. The key components of the intervention (a dedicated facilitator, education and training, audit and feedback) must be configured to influence the beliefs of staff in relation to end of life care, and increase their motivation and self-efficacy in relation to using the LCP. The support of senior managers is vital to the release of necessary resources, and a dominant culture of cure, which sees every death as a failure, works against effective communication and collaboration in relation to the LCP.

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